The Parks at Garland Healthcare and Rehab

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for residents' monthly Resident Council Meeting for 7 of 14 confidential residents reviewed for Resident Council for 1 of 1 facility.1. The facility failed to provide a private space area for residents who attended monthly Resident Council Meetings. This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns amongst each other due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to file grievances anonymously for 12 of 12 residents (Resident #75 and confidential group members) reviewed for grievances.1. The facility failed to ensure that the 93 residents at the facility had access to file a grievance anonymously. The facility's failure could place the residents at risk for concerns not being reported and addressed.

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary for 1 of 3 residents (Resident #2) reviewed for closed records. The facility failed to ensure Resident #2 discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control. CNA A failed to wear the appropriate PPE while providing incontinent care to Resident #1. CNA B failed to wear the appropriate PPE while transferring Resident #1 from bed to wheelchair. LVN C failed to wear the appropriate PPE while transferring Resident #1 from bed to wheelchair. This failure could place residents at risk of being infected by staff in contact with other residents with infections. Review of Resident 1's Quarterly MDS assessment dated [DATE] revealed that she was a [AGE] year-old female. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meals tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 12/09/2025. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of2 residents reviewed for misappropriation (Resident #2). Based on interview and record review, the facility was unable to account for 11 Soma pills missing from Resident #2's blister pack of physician prescribed Soma (muscle relaxant). This failure could place residents at risk of misappropriation of physician ordered medications.

Inspectors wroteBased on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure staff were wearing the appropriate hair and beard coverings. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive plan was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, that includes but is not limited the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, and a member of food and nutrition services staff, for one of three residents (Resident #1) reviewed for comprehensive resident centered care plans. The facility failed to ensure all members of the interdisciplinary team were present for the care plan. The failure placed the residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 1 (Resident #16) of 3 residents reviewed for abuse. The facility failed to protect Resident #16 from physical abuse. Resident #16 was pushed off of his bed, onto the floor by CNA J during incontinence care on 11/29/23. The non compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 11/29/23 and ended on 11/29/23. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for abuse and could lead to serious injury, serious harm, serious impairment, pain, and/or mental anguish.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date food stored in the freezer that should no longer be consumed. 2. The facility failed to discard food stored in the refrigerator that was past use by date and should no longer be consumed. These failures could affect Residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each Resident, consistent with Resident rights, that include measurable objectives and time frames to meet Residents' mental and psychosocial needs for 2 of 4 (Residents #6 and Resident#235) Residents reviewed for care plans. 1) The facility did not develop and implement a comprehensive person-centered care plan to address Resident # 6 noncompliance with Physician orders of using O2 via Nasal cannula. 2) The facility did not develop and implement a comprehensive person-centered care plan to address Resident #235 Significant weight loss of 8.64% in 1 month.) This failure could place resident at risk of not having a plan developed to address care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to conduct activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #1, Resident #2, Resident #3) of 5 residents reviewed for ADL care. The facility failed to ensure Resident #1's facial hair was removed and nails were trimmed and cleaned. The facility failed to ensure Resident #2's facial hair was removed. The facility failed to ensure Resident #3's nails were trimmed and cleaned. These failures could place residents at risk of infections and skin tears resulting in pain, discomfort and decreased psycho-social well-being and self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that each resident received adequate supervision/assistance to prevent accidents for one (Resident #1) of four residents reviewed for accidents in that: Agency CNA A failed to utilize the appropriate safety precautions and amount of assistance Resident #1 required while providing incontinence care for the resident, as a result, Resident #1 rolled out of the bed and sustained a black eye. This failure could place residents at risk for accidents and injury.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1(bathroom room [ROOM NUMBER]) of 6 bathrooms reviewed for pest control The facility failed to ensure Resident bathrooms did not contain live roaches. This failure could place residents at risk of a diminished quality of life due to an unsafe environment.